John La Puma, M.D.

John La Puma, M.D.

An exchange of letters in the Journal of the American Medical Association last year titled "Physician Marketing of Nutritional Supplements" revealed that some physicians have qualms about selling supplements in, from, and out of the office.

Managed care should have a special interest in sales of supplements in the office, and especially in their multilevel marketing practices. Such statistics as the $27 billion spent on supplements annually and the 17 seconds patients speak in the office before interruption attract attention. Selling supplements is often offered as a way to compensate for the pressures of managed care practice.

Ethics is important, but money — that's something to fight about! When the two overlap, as they do in managed care, core principles and strong personal feelings should be sorted out. So should a few pros and cons.

Long history

Dispensing drugs in the office has a long and international history, according to Marc Rodwin, J.D., author of Money, Medicine and Morals (Oxford, 1996).

Why the long history? Access to high-quality special products, for one. You have read the literature about the supplements you carry. You know about these products' integrity — their safety, potency, and consistency — and you want others to know too.

To serve patients well, you will offer access to these high-quality products. You will stock them right next to your prescription samples. Or you will ask your receptionist to phone the supplier directly, with the patient's credit card number, to order "Cholesterol Function" or "Joint Support" or "Fat Burners II" for home delivery for three months. This service costs a little more, but many patients will find it worthwhile.

You yourself find it worthwhile, and will take at least one of these supplements. You modeled healthy habits for patients before, when you quit smoking, and you notice now that patients seem inspired when you tell them how much you understand how hard it is for them to quit, because it was difficult for you as well.

Been there, done that

This modeling behavior may help you with your own ailment, whatever it is, but more importantly, you will be able to tell your patients what it's like to take these supplements.

You know that a financial conflict of interest exists — prescribe more, make more money. But the danger from nearly all of these products is small compared with prescription drugs. You will assure patients that there is no undue influence on your prescribing habits. You will issue a memo, available up front right next to your receptionist, informing patients of your monetary benefit from supplement sales. After all, it is sound judgment that matters, not whether conflicts are present.

You will finally get to do more preventive medicine. You will help promote health, and do more of what managed care was intended to do — improve population-based health by preventing disease. You know that one quarter of Americans get zero fruits and vegetables in a day. Taking supplements will be almost as good and, in some cases, probably better. How else could you get 400 IU of Vitamin E — cups and cups of hazelnuts and almonds?

Code of conduct

Though the practice of dispensing drugs in the office has a history, it has been regulated within the profession.

The AMA's code is specific: "A physician may not accept any kind of payment or compensation from a drug company or device manufacturer for prescribing its products.... A physician should not be influenced in the prescribing of drugs, devices, or appliances by a direct or indirect financial interest in a pharmaceutical firm or other supplier. Whether the firm is a manufacturer, distributor, wholesaler, or repackager of the products involved is immaterial."

You have primarily brand names to go on for quality. There are no mandatory federal or state standards for purity or safety, as the dietary supplement industry is nearly entirely unregulated. You do not find much in the peer-reviewed medical literature about these particular combinations of supplements. You are also unsure of the standards of the journals that publish the articles the company then copies and sends to you.

You have taken some of these supplements — no problems. But ever since you've quit smoking, you seem to gain weight just by looking at cookies. Sometimes you find yourself forgetting to take the supplements, but eating cookies at night, when you're not even hungry. Sure you would like to be a model for your patients. But it's hard.

You believe that supplements probably provide false security. Nearly all the data about cancer prevention and heart disease reversal have been accumulated using food and lifestyle interventions, without supplementation of even antioxidants.

You also know that patients will have to pay more through your office for supplements than they would at the drug store. You regret this, as medicine is too expensive for your patients already. You know that pharmacists have less time too, and this too you regret, as they might have caught any errors you made in recommending supplements that could have been purchased in pharmacies.

You know that you are probably influenced by advertising and the promise of earning more, and that supplement companies want access to your good name, white coat, and patient population. You know that you are only human, and that even you have a price. You dislike being used, and being thought of as a salesman. You do not trust this industry, and think most of this hype is about marketing, not science.

You would feel uncomfortable disclosing a 40- to 60-percent markup, but you suspect that even if you do, it will not influence patients' judgment. Patients recognize that physicians have gone commercial and everyone knows why: managed care. Ask yourself:

  • Am I trained to evaluate nutritional needs?
  • Can I be objective enough to use practical wisdom and to not give too much, too little, or inappropriate care?
  • Is selling supplements likely to provoke or intensify medicolegal conflicts?

John La Puma, M.D., is a Chicago-based internist and author of Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics, Hatherleigh Press, New York, 1998. He practices at Alexian Brothers Medical Center in Elk Grove Village, Ill.

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